title: Multilevel dynamic systems affecting introduction of HIV/STI prevention innovations among Chinese women in sex work establishments.
abstract: Social and public health scientists are increasingly interested in applying system dynamics theory to improve understanding and to harness the forces of change within complex, multilevel systems that affect community intervention implementation, effects, and sustainability. Building a system dynamics model based on ethnographic case study has the advantage of using empirically documented contextual factors and processes of change in a real-world and real-time setting that can then be tested in the same and other settings. System dynamics modeling offers great promise for addressing persistent problems like HIV and other sexually transmitted epidemics, particularly in complex rapidly developing countries such as China. We generated a system dynamics model of a multilevel intervention we conducted to promote female condoms for HIV/sexually transmitted infection (STI) prevention among Chinese women in sex work establishments. The model reflects factors and forces affecting the study's intervention, implementation, and effects. To build this conceptual model, we drew on our experiences and findings from this intensive, longitudinal mixed-ethnographic and quantitative four-town comparative case study (2007-2012) of the sex work establishments, the intervention conducted in them, and factors likely to explain variation in process and outcomes in the four towns. Multiple feedback loops in the sex work establishments, women's social networks, and the health organization responsible for implementing HIV/STI interventions in each town and at the town level directly or indirectly influenced the female condom intervention. We present the conceptual system dynamics model and discuss how further testing in this and other settings can inform future community interventions to reduce HIV and STIs.
authors.affiliation: 1Institute for Community Research, Hartford, CT, USA.
authors.forename: Margaret R
authors.initials: MR
authors.lastname: Weeks
authors.forename: Jianghong
authors.initials: J
authors.lastname: Li
authors.forename: Susu
authors.initials: S
authors.lastname: Liao
authors.forename: Qingning
authors.initials: Q
authors.lastname: Zhang
authors.forename: Jennifer
authors.initials: J
authors.lastname: Dunn
authors.forename: Yanhong
authors.initials: Y
authors.lastname: Wang
authors.forename: Jingmei
authors.initials: J
authors.lastname: Jiang
mesh_terms: D000884:Anthropology, Cultural; D002681:China / Q000453:epidemiology; D002947:Cities; D003153:Community Health Services / Q000379:methods* / Q000458:organization & administration; D019111:Single-Use Internal Condom / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D006801:Humans; D007398:Interpersonal Relations; D008962:Models, Theoretical; D011157:Population Dynamics; D021841:Safe Sex / Q000706:statistics & numerical data; D060386:Sex Workers / Q000523:psychology / Q000706:statistics & numerical data*; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000517:prevention & control*; D012944:Social Support; D013598:Systems Theory; D000078329:Workforce
keywords: China; HIV/STI prevention; multilevel intervention; system dynamics model; women sex workers